Do We Need Support in Prepectoral Breast Reconstruction? Comparing Outcomes with and without ADM

Abstract

Background: The majority of two-stage prepectoral breast reconstruction has been described utilizing acellular dermal matrix (ADM). Although reports of prepectoral breast reconstruction without ADM exist, there is a paucity of comparative studies. Methods: A single-institution retrospective review was performed of consecutive patients undergoing immediate prepectoral two-stage breast reconstruction with tissue expanders from 2017 to 2019. Short-term reconstructive and aesthetic complications were compared between cases that utilized ADM for support and those that did not. Results: In total, 76 cases (51 patients) were identified, of which 35 cases utilized ADM and 41 did not. Risk factors and demographics were similar between the two cohorts with the exception of body mass index, which was higher in the ADM cohort (29.3 versus 25.4, P = 0.011). Average follow-up length was also longer in patients who received ADM (20.3 versus 12.3 months, P < 0.001). Intraoperative expander fill was higher in patients who did not receive ADM (296.8 cm3 versus 151.4 cm3, P < 0.001) though final implant size was comparable in both cohorts (P = 0.584). There was no significant difference in the rate of any complication between the ADM and no ADM cohorts (25.7% versus 17.1%, respectively P = 0.357), including major mastectomy flap necrosis (P = 0.245), major infection (P = 1.000), seroma (P = 0.620), expander explantation (P = 1.000), capsular contracture (P = 1.000), implant dystopia (P = 1.000), and rippling (P = 0.362). Conclusions: Immediate two-stage prepectoral breast reconstruction with tissue expanders has comparable rates of short-term complications with or without ADM support. Safety of prepectoral expander placement without ADM may warrant more selective ADM use in these cases.

Prepectoral Breast Reconstruction Without the Use of Acellular Dermal Matrix: A 3-Year Review

“…When comparing our institution’s outcomes, we found that prepectoral tissue expander reconstruction had no statistically significant differences in total complication rates, major complication rates, infections rates, or explant rates in comparison with historical subpectoral reconstructions with the use of ADM. In addition, our reported complication profile and explant rates were comparable with recent literature’s reported outcomes 11,12,14,25 . Our experience suggests that the tissue expander phase of prepectoral breast reconstruction can be performed with a similar complication profile seen in patients who underwent subpectoral breast reconstruction with ADM.…”

“…A number of surgeons perform prepectoral reconstruction with the use of ADM citing either improved prosthetic position control or additional soft tissue coverage in the event of skin compromise 24 . However, design modifications to tissue expanders, such as the fixation tabs, now allow surgeons to secure expanders in place without the need for ADM 12–14 . Furthermore, in the event flap necrosis with exposed unincorporated ADM, most surgeons operatively revise just as they would with exposed prosthesis.…”

“…Proponents of prepectoral ADM prosthetic coverage cite additional soft tissue coverage in the event of mastectomy flap breakdown and superior control of implant position in the mastectomy pocket 12 . In practice, either implant exposure or nonincorporated ADM would prompt operative revision, while tissue expanders are now designed with fixation tabs for positioning purposes 12–14 . Despite the proposed advantages of ADM, the documented disadvantages of ADM use include cost, increased seroma rates, and increased infection rates 10,15 …”

Reply: Catch-22: Acellular Dermal Matrix and U.S. Food and Drug Administration Premarket Approval – How Can We Construct Studies?

“…Specifically, the authors comment that ADM has "enabled prepectoral breast reconstruction," implying that the procedure cannot feasibly be performed without ADM. Yet, several surgeons have reported reassuring results in patients without ADM. [4][5][6][7][8] We had previously performed a systematic review of the literature on all reported prepectoral patients undergoing reconstruction with and without ADM and identified no significant differences in complication rates. 9 In addition, several publications have identified possible safety concerns with the use of ADM in submuscular reconstruction.…”

Early Complications in Prepectoral Breast Reconstructions with and without Acellular Dermal Matrix: A Preliminary Analysis of Outcomes

“…Unfortunately, few studies have compared prepectoral reconstruction with and without ADM in a head-to-head manner and lack sufficient size for adequate statistical power to determine true differences. 19,20 The aim of this study was to obtain a preliminary understanding of early complication rates (within 90 days) between patients who underwent prepectoral TE placement with and without ADM. The hypothesis is that the absence of ADM would not change rates of explantation and overall short-term complications.…”